Augmented Reality-Assisted Extracranial-to-Intracranial Bypass Surgery

Aim: Harvesting of a donor vessel and the choice of a recipient vessel are two essential steps during extracranial-to-intracranial (EC-IC) bypass surgery^1-3. Manual pulse palpation, Doppler probes and angiographical “road-mapping” have been used to draw the trajectory of the extracranial donor vessels; and the identification of an appropriate intracranial vessel is based upon detailed analysis of the preoperative angiography and on intraoperative inspection of cortical vessels. Augmented reality is defined as the overlay of virtual images upon real-world structures, and this technology has been used in various surgical settings^4,5. We investigate the usefulness of augmented reality-based microscope image-injection during these two phases of EC-IC bypass surgery.

Methods: Patients’ intracranial and extracranial vessels of interest were segmented from preoperative 3D rotational angiographies, using BrainLab’s Iplan platform (BrainLAB, Feldkirchen, Germany). Furthermore, chosen points of anastomosis were marked. Patients and the operating microscope (Zeiss Pentero 600; Zeiss, Oberkochen, Germany) were coregistered to the neuronavigation station (Kolibri™; BrainLAB, Feldkirchen, Germany) and the 3D segmented images were injected into the microscope’s eyepiece for intraoperative guidance.

Results: From November 2012 to November 2013, n = 3 patients were operated for bypass surgery (n = 2 STA-MCA; n = 1 occipital artery-PICA) using augmented reality. Donor arteries were accurately localized and did not incur damage during harvesting. Image injection was particularly helpful with the occipital artery’s tortuous course, and harvesting was thereby expedited. In all cases, minimal craniotomies were performed, tailored to the injected images of the chosen points of anastomosis, and the preoperatively chosen recipient vessels were easily identified. Overall, augmented reality was considered useful by the surgeon in all three cases.

Conclusions: Augmented reality can evolve to be a useful and easily applied tool during EC-IC bypass procedures. It helps to harvest donor vessels by accurate localization, to tailor craniotomies and to intraoperatively identify, through image superposition, the recipient vessels that have been selected from preoperative angiography.

References

References

1 Kawashima M, Rhoton AL Jr, Tanriover N, Ulm AJ, Yasuda A, Fujii K. Microsurgical anatomy of cerebral revascularization. Part I: anterior circulation. J Neurosurg 2005;102(1):116-131

2 Kawashima M, Rhoton AL Jr, Tanriover N, Ulm AJ, Yasuda A, Fujii K. Microsurgical anatomy of cerebral revascularization. Part II: posterior circulation. J Neurosurg 2005;102(1):132-147

3 Wanebo JE, Zabramski JM, Spetzler RF. Superficial temporal artery-to-middle cerebral artery bypass grafting for cerebral revascularization. Neurosurgery 2004;55(2):395-398, discussion 398-399

4 Shuhaiber JH. Augmented reality in surgery. Arch Surg 2004;139(2):170-174

5 Cabrilo I, et al. Augmented reality in the surgery of cerebral aneurysms: a technical report. Neurosurgery 2014;10:252-261